University Of Texas Rio Grande Valley Depression and Bipolar Mania Discussion

Question Description

a). Initial Post

Consider your prior Learning for Depression and Bipolar Mania.

How would your treatment plan change for a pregnant female? For a lactating female?

What patient teaching would you include?

b). Response Post

Review your peers responses and respond to at least two classmates.

What did you learn?
Did any topics provoke interest in further learning?

RESPONSE NUMBER ONE.

Psychotropic Medications During Pregnancy and Lactation

COLLAPSE

Psychotropic Medications During Pregnancy and Lactation

Over the last 10 years, SSRIs have been some of the most frequently prescribed antidepressant medications during pregnancy and the postpartum period. There have been conflicting findings in the risk versus benefit regarding safety of these drugs. A recent study did a risk/benefit balance analysis based on the best and most up to date research and found it nearly impossible to distinguish the potential negative effects of maternal depression and those related to SSRI treatment. The experts opinion stands that women suffering from major depression and currently responding well to medication treatment, should be encouraged to continue their regimen in order to prevent complications and preserve infant-maternal bonding (Weisskopf et. al., 2015). Education, however; should be provided on an individual basis so that patients can make an informed decision for themselves with the help of their provider based on the severity of their mental illness and their concerns during pregnancy or lactation. Antidepressant medications do cross the blood-brain barrier and the placental barrier and may increase mediators in the developing fetus. Adverse effects of this may be related to the functional growth of the brain, potentially leading to a risk for emotional, cognitive, neurobehavioral, or mental disorders (Dubovicky, 2017).

Similar to the SSRIs for depression, the medications prescribed for bipolar disorder have been a topic of debate among healthcare providers during pregnancy and with lactation. A review of several recent research studies regarding the atypical antipsychotics specifically found no consistent or substantial risks when compared to other psychotropic medications. Also, several studies found that medications previously considered teratogens, such as lithium, were shown to have a much lower risk of malformation than originally reported. In this review, the recommendation was a patient-centered approach, using minimal effective dosing of necessary bipolar medications to provide the best outcomes for both mother and child (Swetlik & Viguera, 2018). Decision making for pharmacotherapy treatment for bipolar disorder during pregnancy must consider many fluctuating factors, including psychosocial supports, past pregnancy treatment outcomes, severity of a patients illness, and drug responsivity. Many psychiatric prescribers will avoid carbamazepine and divalproex but consider lamotrigine a fairly safe option. The second-generation antipsychotics are all considered relatively safe as long as there are limited maternal adverse effects, such as extrapyramidal symptoms (Albertini, Ernst, & Tamaroff, 2019).

References

Albertini, E., Ernst, C. L., & Tamaroff, R. S. (2019). Psychopharmacological Decision Making in Bipolar Disorder During Pregnancy and Lactation: A Case-by-Case Approach to Using Current Evidence. Focus, 17(3), 249-258. doi:10.1176/appi.focus.20190007

Dubovicky, M., Belovicova, K., Csatlosova, K., & Bogi, E. (2017). Risks of using SSRI / SNRI antidepressants during pregnancy and lactation. Interdisciplinary Toxicology, 10(1), 30-34. doi:10.1515/intox-2017-0004

Swetlik, C., & Viguera, A. C. (2018). Management of Bipolar Disease in Pregnancy and Lactation. Current Treatment Options in Psychiatry, 5(4), 425-440. doi:10.1007/s40501-018-0161-1

Weisskopf, E., Fischer, C. J., Graz, M. B., Harari, M. M., Tolsa, J., Claris, O., . . . Panchaud, A. (2015). Risk-benefit balance assessment of SSRI antidepressant use during pregnancy and lactation based on best available evidence. Expert Opinion on Drug Safety, 14(3), 413-427. doi:10.1517/14740338.2015.997708

RESPONSE NUMBER TWO

Psychotropic treatment plan for Pregnant and Lactating females

Psychotropic Treatment Plan for Pregnant and Lactating Females

According to Grover and Avasthi (2015), management of bipolar during pregnancy and postpartum is very challenging. The treating clinicians have to take into account various factors like current mental state, longitudinal history of the patient, past history of relapse while off medication, response to medication, time of pregnancy at which patient presents to the clinician, etc. The choice of drug should depend on the balance between safety and efficacy profile. Whenever patient is on psychotropic medication, close and intensive monitoring should be done. Among the various mood stabilizers, use of lithium during the second and third trimester appears to be safe. Use of valproate during first trimester is associated with major malformation and long-term sequelae in the form of developmental delay, lower intelligence quotient, and higher risk of development of autism spectrum disorder. Similarly use of carbamazepine in first trimester is associated with higher risk of major congenital malformation and its use in first trimester is contraindicated. Data for lamotrigine (LTG) appears to be more favorable than other antiepileptic. During lactation, use of valproate and LTG is reported to be safe. Use of typical and/atypical antipsychotic is a good option during pregnancy in women with bipolar disorder.

Antidepressants have been increasingly used during pregnancy in the past few decades, with approximately 2-8% of pregnant women receiving this treatment. Selective serotonin reuptake inhibitors (SSRIs) are the most commonly prescribed antidepressants. Some recent studies have raised concerns about behavioral problems in the offspring. So far, population based studies of long term neurodevelopmental outcomes have focused primarily on autism spectrum disorder in children exposed to SSRIs in utero. Some studies reported an increased risk, whereas others suggested no association. The magnitude of the relative risk of autism spectrum disorder for in utero exposure to SSRIs compared with non-exposure ranges from 0.83 to 3.34. Findings on in utero exposure to SSRIs and attention-deficit/hyperactivity disorder (ADHD) are also contradictory; in utero SSRI exposure was associated with increased risk of ADHD in one study, but not in others. The underlying mechanism linking in utero SSRI exposure and behavioral problems is unclear; however, one theory posits that SSRIs cross the placental barrier and affect fetal brain development. If this theory holds true, in utero SSRI exposure may increase risks of other psychiatric disorders as well as autism spectrum disorder and ADHD. This assumption is supported by two recent studies investigating other diagnostic groups of psychiatric disorders in children and adolescents besides autism spectrum disorder and ADHD, including depression, anxiety, neurobehavioral and social development, and speech, scholastic, and motor disorders (Liu et al., 2017).

Untreated maternal psychiatric disorders can have devastating sequelae. Pregnancy-associated suicide kills more women than hemorrhage or preeclampsia, underscoring the importance of screening and treatment for perinatal mood disorders. Moreover, depressive symptoms are associated with adverse parenting practices, including reduced use of safety and child development practices and increased harsh punishment9 including suicidal ideation and/or fears of hurting the newborn. In addition, postpartum depression is associated with reduced maternal sensitivity, which may adversely affect development of infant emotional regulation and attachment. Insecure attachment, in turn, increases risk of psychiatric disease in the child. Given the harm to both mother and child associated with untreated perinatal mood disorders, the U.S. Preventative Health Task Force and the American College of Obstetrics and Gynecology recommend universal screening for perinatal depression. With increased recognition of the consequences of perinatal psychiatric disorders, information about the efficacy and side effects of treatments is needed to inform clinical decision-making. Treatment choices include pharmacotherapy, psychotherapy, and other approaches such as yoga, mindfulness, self-care, nutritional or herbal supplements (AHRQ, 2019).

References

Agency For Health Care Research and Quality (2019). Maternal and Fetal Effects of Mental Health

Treatments in Pregnant and Breastfeeding Women: A Systematic Review of Pharmacological

Interventions. Retrieved from https://effectivehealthcare.ahrq.gov/products/mental-health-

pregnancy/protocol.

Liu et al (2017). Antidepressant use during pregnancy and psychiatric disorders in offspring: Danish

nationwide register based cohort study. BMJ, 358. doi: https://doi.org/10.1136/bmj.j3668

Grover, S., & Avasthi, A. (2015). Mood stabilizers in pregnancy and lactation. Indian journal of psychiatry,

57(Suppl 2), S308S323. https://doi.org/10.4103/0019-5545.161498

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